S 1212 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES-USE BALL POINT PEN ONLY
CITY OF CUPERTINO ❑UIhDING-F.LP:C'fRll'AI, PUS\qIT NO
BI1n,DINO DIVISION APPLICATION/PERMIT PLUN BING.MECHANICAL . V 1212
BUII,IIING PRO.1irCT iDENriFICA'FION
BUILDING ADDRESS: SANITARY NO. APPLICAf1ON SUBMITTAL DATE
1095/ S LUUf!- RA • 2--j- ,00
O NIBt'SNA=ii� !� I—H�„ � (6/ C'ONTOCI'ORS NA li: /S Co . LIC NIP, NIC (:ON'I ROLA
ARCHII ECTIIEYYNGINEER: LIC NO: ADDRESS:: ❑
5 � o
CONTACT. �E &M I'nONE: BUI ELECT PPIi LU INFO
8 7— ❑ Consultant Fces Paid by Applicant(initial) BLDG GLI[cr rLumO MECx
✓iQAn/�iT fin Aye �� ss-5- ❑
LICENSEDCON'FRACIORS DECLARATION QTY ELECTRIC PERMIT FEB
I hereby affirm that l am licensed ander provision of chapter 9 hus"wr ting 306 DESCRIPTION
WOOnixZ with Sections 700(pof Division 3oftheBminess and Professions Code.and my
lice old is RESIDENTIAL:
Fwd in full force and effect. I'IiRMI'1'ISSf1ANCF.
y•W•- ❑SFDWI. ❑PLUMBING RE PIPE 6VU Date cclass Curab AITUANCIdS-RESIDEN'I]AI. ❑Al)lll'110N ❑PLUMBING RI?-PIPH
hQL UWc Cunlmclor
ARCHITECTS DECLARATION ❑MU1.1'1-UNIT ❑STRUCTURAL•
p.,W m PANELS
ZOr-Z IundersmnJ my plans shall ho used us public mmM.c MODIFICATION
OZ—c UI"T02W AMT'S ❑INTHRIOR ❑CHIMNHV REPAIR
241W W Licensed Pis he”opal 2 H-IM) P, IMPROVEMHN'1' ❑SWIMMING POLLS
Y 2; OWNlilt-BUILDER UECLARAT'ION OVER 11000ASIRS ❑BA'I'll REMODEL)REPAIR ❑DEMOLITION
tY C st I hereby afford that 1 an exempt from he Cornmaor's License Law for the n nn
6OLV Ibllowin reman.IScction]03L5.Business unA fmfeasinna Crile An r t ❑OTHER FW A( F.f���
g y co court y SIGNS ELECTRICAL
rq which occuire,u permit to comlra d alter,improve,demelinh nr rga.ir uny sa e....c
q priomoll.e iaxmmce,alaom,mma the applicant linsuch permilm file a signed ctatenmnt SPECIAL CIRCIII'I MISC.
Ibvt he is hem,edpursnam to flcprnvivions of the Contractor's License].use(Chapter 9
�o'a,p Emnmcncing with Section 700 of Division 3oflhe Business and Professions Foodc)or TEAM METER OR POLI:INST. COMMERCIAL
d{y o e• that he is exempt therefrom and the basis for the alleged"emption.Any violation of ❑NEW HI.DGIADDITION ❑DEMOLITION
W;fin Scdion]031.5byanyappherna❑na permit xuhjecls the rmplicanun,civil penalty al POWER DEVICES ❑THNANT ❑FOOD SERVICE
not mare than rive hundred dollars($5W).
RED Y IMI'NOVEMfiN'1'
6 wiLothe work,lbs prostardmmyemployers with
ered loetheirwle cnmpen.sines, SWIMMING I'OIILELF kl
�_� will dolhewons and the seContatnor s License
awdosnot apply ][a14,Business ❑DT111:R
W0.3 m and edy who t ids or The oyes driers,
Liceron Law,lot not work
ha ,if snener of OUTLETS-SW ITCHP_S '1 ES
.. prndxrty whooyees or improves Ihsuchi and who dmea amh work hlmxdf ar Ihmugh
his own employees bidding
that such older,vetnenl+mrc urn dor fJ or offered lin N1iW RESIDEN'T'IAL ELEC It :Q FT.
momebuildever,thh buildingndmpmvemcm iia,he did ntbuild rofennpletfor put- SQ.FT.FLOf1RAREA ASQ.Fi.
nwncrbuilJer will have the M1UNen of proving that he did urn build or inlpmve for pur-
plsc of sale.).
grpf 1,as owner M'the mco ly,stn axeWsively canuall log wldl ler,nsel sunaura,oars It, loo"'1510 01AI"
(nnstood the prnjeer(Sec]BW,Busines and Professions Code:)Inc Contractors Li-
cencelawdoesnnlapplytoanownerofpe)NHy who builds or improves thereon.trod QTY. PLUMBING PERMIT FEE
who commew for such projects with a cmnractims)licensed pursuant to the Contractors
Licence law. PERMIT ISSUANCE
0oot exem unJm Sec. B&PClm this re inn
Owns ate A]SEE-DRAIN&VENT'-WATER(];A) VALUATION
WORKER'SC 1P[NSAI'ION DECLARATION BACK FLOW I'kOTF.CT.DEVICEI hereby uffinn soder pct ally of perjury nuc of❑m following Aeclurmions'.
❑ Ihvvd vntl will tnainlaina Ccrliliule of Cnnsenl to aelflnwre for Worker's Conlpnl- DRAINS-FLOOR,ROOF.AREA.GOND,
cation,as provided for by Section 3]00 of the latae Code,for the performance of the STORIES I'YI'E CONS'1'RUCT'IUN
'
work for which this .is is issued. FIXTURES-PER THAT
I have and will maintain Worker's Compensation Insurance,m required by Section
3700ofthe LuhnrCade,bis thtfinfammad of rho work fur whichmi,stonil is Laaaet, GAS-EA,SYS'113M-1INC,4 OUTLET'S OCC.GROUP APN
My Workers Compensation Insurance carrier and Policy number are
Cartier: Policy No, GAS-EA.SYSTEM OVER 4(EA)
CERTIFICATE OF COMPENSATION
FROM WORKERS'
COMI'F.NSATI(1NlNSURANCE GRIiASF/INDl1S'fRL WAS IT INTERCEPTOR
BUILDING DIVISION Id?FS
(fhia section need not hu urmplotdd 11 rte pennh In li,nind bmndrcd Jalbars($Itxq GItPASE TItAI'
or It,,.) PLANCHIiCK FEE
Icenify the inme performance aidework w.orwhiehthispemlit isissued'Comshall SEWER-SANI'T'ARY-S'DORM EA.NNI IT.
not employ uny person in any manner so as m M1ecome snhject m the Workers'Cnmpen. ENERGY TEF.
is, Lawsof Culifomia.Dme WR'I'ER HEAT'17R WNENTIHLCCTR
Z Q Applicanl GRAVING FEE
fin NOTICE TO APPLICANT:IL after making this Cenifictne of Exemption,you should WATER SYSTEM TREATING
a ? here subjeel ,,the Worker,Compensation pmciafana of the Labor Cale,you mea SOILS FEE
Lia fnnhwithcomply withsuch IF siumemhiapermilshvll hedeemalevoked. WNIERSERVICE
:D Q
GDt them is aconNI.ItNDINGAG1geCY NEW R13SIIlIiN'IIAL PLMII. SQ.FT PAID
rti Z Ihereh Ron that Then:is construction lending for formancc of Date Receipt
L) ye. .agency per
rhe work for wch this pemrit is iw.ssued(S1p>].Civ.CJ
Q hif•` Lcndcr'c Name TOTAL:
1..J Irodus Address TOTAL
1 cenily that I have read this application and.dale the the uMrvc information is BUILDING FEE
h correct.I agree to comply with all city and county ordinances and state laws miming in QTY. MECHANICAL PERMIT FEF•
V 2 building con+tmetion,and hereby immunize mimsematives of this city to enter urym the SEISMIC FEF.
uhov✓otemaxod property for inapcction pmpoma PERMIT ISSUANCE.
(We)agree It,sued,lndenmidy and keep[in rnrless the CID of Cltpertim,ngain4 ELECTRIC FEF.
Iiabilities,judgmems,costa and expenses which may in any way accrumtgainst said City ALTER OR ADD TO MECII.
in em+,primee of the granting of lhis permit. PLUMBING FF.F.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON-POINT AIR HANDLING UNIT(TO IO.WCFM)
SOURCE REGULATIONS. MECHANICAL FEE
A I R HAND[.I NO ON IT EIV IIR 10.000 CIM) CONSTRUCTION TAX
Signature ofAlaphem/Cmumdor Done FXIIAUS'T HOOD(Wilto HOUSING MITIGA9'ION FEE
HAZARDOUS MATERIAIS DISCLOSURE
WIII the applicant or future hullding aa'upmt Moorhandle hvanlam ntmcriul I IVAUNG UNIT U 0 1(M.WB It'U)
as defined by We.Copcnina Municipal Codc,Chapter,9.12,and me Ilelhh end Solely
Gale,Section 25532(a)' IIIHATINO UNIT(OVER hn,000 BTU)
Yes FT No
VEN'HLATIONFAN(SINGLERESID) PAID pate Receipts
Will the applicam or more huilJing occupnnl use crluipment or devices which
emit hoe.Noma air—mamlnams as defned by the Bay Amu All Quality Manvgement BOILER-COMP011POR fp.ofo B'fll)
District? '1'O 1.:
❑Yes ❑No BOILER-COMP(OVER I H(00 BTIll
I have ocal the hazvninna mnleriuLa rcqu'vementx under Chader 6,95 ofthe Call. AIR CONDI'I ONER ISSUANCE IJA9 F,
fomia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the NEW RESIDENTIAL MECIL SQ.FT. //�� !7T/
budding da
Sees,nm currently have a tenant.rat it is my marymsihility to notify the occupant -`
V Y R O/
of the requirements which must M mel prior to ismence of a Certificate of Occupancy.
Owner or authorized agent DateTDTA a ISSUED BY:
OFFICE